Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Thursday, June 19, 2008

Most of you must know of the Libby Zion case some 15 or so yrs ago. If not, briefly, young lady dies of infection after being in a NY teaching hospital ED waiting for care.

This episode changed medical education in a huge way, as residents(drs in training) are now forbidden to work more than 80 hrs/wk and more than 36 hrs in a row. Obstensibly, to prevent fatigue and reduce errors in medical care leading to this sort of "outcome" (and now the hrs are soon to be reduced to 57 hrs/week!)

My personal record as a resident BP (before penicillin) of continual service was, without stop or sleep, Friday 6AM until 3PM the following Monday..(neurosurgery rotation)

Despite the good intentions, the objective data, show that this reduction of hours has INCREASED poor outcomes, mistakes, etc. Probably due to the increased number of "turnovers" which is what we call signing the patient over to a new doctor before diagnosis, definitive treatment, etc is established by the initial treating physician.

The reason for our previous long hours of work during residency, was continuity of care, so that a young physician would see a case thru the initial stabilization and treatment of a patient and see the progression and effect of said treatment.

Doesn't seem to have worked as intended. So would your rather have a tired doctor directing your care who knows exactly what has gone on in the initial stages of your treatment or a fresh doctor who takes over but doesn't know what or how ill you were 36 hours ago??

55 comments:

I would rather have the tired doctor who knows what's going on. I would hate to have to explain something to a new doctor when I was all hopped up on morphine or something. It's bad enough having to go over symptoms with the nurse and doctor the first two times while sitting there in excruciating pain.

For the record, I only go to the ER when I am in excruciating pain. If it's not an emergency I see my regular doc.

i am of two minds on this. was the 'old system' ridiculous? yes. is the new solution better or worse? worse, and mostly for the reasons you mention.

a friend recently out of ortho residency in NY told me that the residents would arrange it quietly amongst themselves to do it the old way so they could have 1.5 to 2 days out of the hospital per month. otherwise it's every day for 5-7 years.

Handoffs suck, especially with the post call residents going home "early"(still after being up for potentially 30 hours)and the night guy getting the handoff from someone just covering. The old system sucked to, especially if you were the patient I was seeing at 4:59 pm on my postcall day. Pulmonary Edema? take 2 lasix and call me in the morning.

So would your rather have a tired doctor directing your care who knows exactly what has gone on in the initial stages of your treatment or a fresh doctor who takes over but doesn't know what or how ill you were 36 hours ago?? Damn, farty, is there a third option?

Going into third year of med school, gimme 80+ hours and a golden weekend every month to do my laundry. I'd rather have a clue and lose some sleep than try to piece together the puzzle of the cluster f**k that went on last night while the other dip-sh!ts were covering.

I'm sorry oldfart, but I think that you are comparing apples to oranges.

PandaBearMD had posted on this very issue numerous times.

In essence, the rate of churn has greatly increased since your neurosurgery days. The acuity of admissions today far exceeds those of your day.

At my institution, admissions that qualified for the MICU a little more than couple of years ago now are routinely admitted to a general floor. Patients who were routinely admitted are now discharged from the ED set up with outpatient appointments.

The inpatient population is much, much sicker than years ago and is going home a whole lot sooner.

be prepared for a flaming arrow from oldfart. he has seen it all in his decades long career, first as a resident, then as an academic director, then in private practice, and again now in academics. he is, iow, the man, albeit an old and grumpy one.

i do not disagree about acuity and patient overload... see voluminous prior posts on EMTALA.

uh, yeah. we don't know what hard work is sparky... i guess and you guys are having it a lot harder than before the residency work hour limitations. i'm sure it's completely different than when most of us finished residency all those years ago (one of us 4 years ago). also, my father can beat up yours.

to drop the sarcasm for a bit i know you are a recent visitor here and welcome your comments but for as long as we've been writing here we are kinda banging the same gong you are right now.

the only perspective you have on this is what you are experiencing right now and stories about 'what it used to be like'.

oldfart is still in full time practice as am i as is s'cat and erdoc85. and we did residency without any sleep after getting up before we went to bed and walked backwards through the snow for six miles to get to the hospital and godammit, we liked it!

You know what though, even though they reduced the hours, my friend recently finished up his residency at the U of A. He still did the huge volume of hours. I asked him about the federally mandated reduction, and he said they(the hospital) actually ignored it. If anyone complained he said they'd basically get booted from residency.

I can't say as to which I'd rather have. I suppose I want the smartest most informed guy. I hate the thought of how tired residents get though. It just maked me ache to think about it because I've gone without that much sleep with a new baby, and I don't even remember what I did or how I survived. Of course that could have been the bloodloss clouding my memory...

here's the way sign out went at my residency. there wasn't one. we did run the board with the oncoming shift but we did not turn over patients until we were senior residents and only then if the oncoming would accept.

this created it's own problems, mainly jockeying for charts towards the end of the shift... no workups, only 'chip shots'.

Here, let me spank you--WHAP! I figured you hated my blog or something. Haven't seen you comment for like 6 months, dude. You're scared of the lowercase-letter retaliation, aren't you?

Now, if you promise to do detailed sign-outs with the knowledge that even "admitted" patients who are just awaiting an inpatient bed are going to sit down in the department for hours and hours, I promise to spank you again. Doctor sign-outs should be as nauseatingly comprehensive as nurse report, if not more.

One positive thing about sign-outs is that if a crappy doctor was on first and was too layzee to do a central line or too much of a dick to intubate a patient in distress or whatever, we get a second chance with the new doctor coming on.

This is an old subject but I remember the Attendings in 1986 saying the same things about the Residents then. Dadburn it some of them were married, and got paid 20K a year, and had a fancy lab to do those Blood Counts. Oy Vey!

Nurse K, at my most recent residency one of the female residents would put frowny or smiley faces next to her patients to indicate if they were sick or stable. Most of the other checkouts consisted of Name, Room or Bed #, Diagnosis and Code Status. Some of the more OCD residents insisted on more detail, but that was enough for me.

I left this comment over at ruraldoctoring a while back but perhaps it bears repeating.

Seriously!? you are a physician for crying out loud, you do not have a nine to five job unless your in Dermatology or an Allergist, I can say that because I am an Allergist. My colleagues whom I did Pulmonary/CCM training with worked much harder and longer hours in private practice than they did during residency or fellowship. I have to wonder how this will effect the 'work ethic' of people coming out of training and going into practice.

"I'm sorry Ms. Peel but the doctor is no longer in the hospital to take care of your crushing substernal chestpain, he will be back at 9am tomorrow morning."

I'm not saying we need to maintain the whole 'rite of passage' thing but 56 hours? Personally I would rather be cared for by a tired doctor who has the ability and character to balance his/her life for the 3-5 years it takes to go through a residency working 80 or more hours a week than the well-rested, can't stay for rounds because my times up, sissy pants that may be coming down the pike.

According to Wikipedia Libby Zion died in 1985 from Serotonin Syndrome resulting from a combination of demerol and a MAO inhibitor. Never understood why MAO had to be inhibited, he's been dead since 1976.

It amazes me that residents are so protected today during residency. How do they expect to function after they get into the real world? Many specialties pull more than 80 (or 57) hours/week after graduation...just ask my brother the orthopedist or my brother the anesthesiologist.

And worse, many of the residents I see rotating through the ED now seem to think that this work-week limitation precludes them from spending time outside the hospital reading up on what they see while -in- the hospital, so that their entire medical education must be compressed into that 80 hours/week.

I'd far rather be taken care of someone who is tired but who has the gumption to spend the extra time learning, thank you.

Dear Scut, thanks for your mis-begotten comments. Not sure where you do your training. At my program, we had a 30% admission rate. At my new program our admission rate is currently 26%, so, no I'm not comparing apples to oranges.Are there conditions we see now that we treat differently? Yes. Does that mean there are actually less sick? No.For instance, kidney stones. Now we admitted all of them 30 yrs ago. That w/u took, oh, 5 mins of time. Now we know the vast majority can safely go home. That's not a less sick pt, that's advancement in medical knowledge. At my current program, non-intubated MI's go to the floor. Is that a less sick pt than 30 yrs ago. No, it's because of advances in treatment and care.I could go on and on. Let's see, what else? Oh yeah, passive restraints,helmets, etc. Didn't exist 30 yrs ago. You pansy ass Phucks don't know shit about trauma care, Spinal fx's, epidurals, smashed spleens and livers..Go right on believing you got it hard, son, cause you won't the sigmoid from shit when you finish in 3 yrs..Too bad for your patients..And as for those "statistics" I DIDN'T quote. They aren't mine. They are vetted by the best educators in the world. They are valid and the reasons tested. I would have never believed what they showed. I would have bet money the opposite wwould have been true, but it ain't.You and you contemporary's are PUSSY'SI'm really too tired from work today to be more succinct today.

I just googled "medical resident hours" and I saw an article from the New England Journal of Medicine that in 2004, there was a lower rate of serious medical errors from interns in the traditional call system vs. those with the shorter call.

I'm not sure how that jives with what you're saying. Common sense would say that if you are better rested, you will make better decisions. Handoffs are an issue, but if other industries can figure it out, I'm sure medicine can figure it out.

Young Seeker, that's exactly why I posted the question!! It does not make intuitive sense but that's what the statistics say after a decade or so of reduced hours..Your education and patient's welfare are being compromised by the "progressive" (read Liberal's) restriction on duty hours.."Other" industries do not deal with unseen variables with which we work..A pipeline is a pipeline 24x7. A 747 is the same plane 24x7..The human organism changes second by second and so do the illnesses that attack it..

I just googled "medical resident hours" and I saw an article from the New England Journal of Medicine that in 2004, there was a lower rate of serious medical errors from interns NEW call system vs. more errors from the old call system.

I'm not sure how that jives with what you're saying. Common sense would say that if you are better rested, you will make better decisions. Handoffs are an issue, but if other industries can figure it out, I'm sure medicine can figure it out.

Oldfart, I often get the feeling that you're too old for this comment battle bullshit. Not too old as in "just can't do it anymore," as that's clearly not the case, too old as in "Dammit, I'm too old for this bullshit!" Something like John McClain would say after killing 12 krauts in an elevator. Let 911 and the kids fight it out; in the meantime, try fly fishing or shoot some animals or go dunk on someone shorter than you. Love your posts though, makes me smile to know that some people are still kickin' it Old School.

Etotheipi: now that I think about it, you remind me of some kind of a Sith lord, like the Emperor. All the other docs here seem to be jedi fighting the good fight against all odds, while you always sneak in a comment or two with a wry smile tempting the righteous to the dark side. The dark side of course being pathology.....its powers.....limitless.

At my intstitution the residents are based at the nearby tertiary care facility. They take no ownership for the patients.There is a day float person who doesn't know jack about the patient. They initially hired two newbie NPs to do the off going team's scut work, but there was little sign out, only a scut list passed down including who to d/c etc. The NPs were clueless. They soon departed. Now we have 2 older seasoned NPs who attend rounds daily, know what is going on and they pretty much tell the PGY1 floats what to do. Seems to work better and improve continuity of care.Our facility has short rotations - one week on ICU/CCU then a week on medicine. So if it is the 6th day of your rotation on ICU and the pt is sick as he!! the MO tends to be, who cares, it is not worth thinking about his issues, do the basics because you'll be gone the next day, let the next guy deal with it.

I'd much rather have a resident trained in the old school than the current method (as long as he had a competent fellow and or staff MD overseeing care).

I don't have a solution, but reducing hours to 56 will only make it worse in my opinion.

Scut, I am BACK in Academics after spending 10 yrs in in private practice EM(an oxymoron) in 1 of the busiest ED's in the nation with ZERO residents or students, waay over 120K/yr. And got tired of seeing less than satisfactory training from more than a few young colleagues(911 exempted)I somehow doubt that provides with me a, what was that, "plantation mentality".I somehow doubt your are an EM resident or you would know that WE are the ONLY teaching physicians who are there 24/7/365, you Pansy Assed Faggot! Supervising, teaching, and seeing patients and in general handling everything no one can, wants to, or has the balls to take care of and hopefully teaching a few good young doctors along the way.

You would not be one of those..Please stay off my blog until you HTFU!!

Ruby, I already do all the above, just not often enuff. And U may be right about being too old. I'd just as soon strangle the little PAFMF, wouldn't take near the strength of typing a response...Kind of like last week, got tired of a certain gen surg and told him he was acting like a chicken shit, fucking highschool bully, do you want to walk outside?Didn't take me up on that either..Toodles..

I am suprised no one has mentioned the nursing staff at the teaching hospitals. Years ago when I worked as a nurse on Medical Stepdown, none of the Interns really made a lot of decisions alone. Most diagnosises has a recipe of what to do. So much of the stuff was ingrained in them. And if they wrote an order like give Magnesium to this patient on dialysis, we would discuss why we could not do that. IF they disagreed, they had to speak to their resident. So it was not like a whole bunch of new guys were set loose on the public. The nurses were watching their every step.

I would say as much learning comes from good nurses as teaching docs. The problem with today(sorry I don't know how old you are) is nurses are getting taught to do paperwork and to actually believe they might be sued for malpractice for a poor pt outcome (that was the drs fault, not theirs)In fact I have never heard of nurse being sued, by themselves, in my entire career. I'm sure it has happened, but there's 30+ yrs of experience here having never seen it.There's a reason nursing malpractice only costs, like $25/yr

Good Nurses Rock!!!Especially ED Nurses!!(Plus they're the best looking, usually have great tits, and are fun, I married one!)

Not to slam on the Nurses, I married one, and I always win those doctor popularity contests they have (Advise to residents, buy a big box of Krispy Kreme Donuts for the Nurses/Unit Secretaries/etal of the floors you work on) might cost $100 or so, so what its Tax deductible. I did it once as an Intern and became known as the doctor who bought donuts for all the Nurses.)but take what they teach you with a grain of salt.

Heres my real point..If continuity of care is so f-in important WHY DON'T the NURSES STICK AROUND 24 HRS!?!? Hmm? Hmm? I know they'll work double shifts occasionally but only for significantly more Cash. And if you're gonna try to get one to teach you something, better not do it around shift change. The only thing I ever asked Nurses for was their phone numbers. Latest Vitals, Physical Exam? They'd tell you to look at the chart stupid, they're busy.

Really who are you kidding? You work an 8-12 hour shift then go home. I trained in the "old days" too and simply the patients in hospital were not sick as they are now (by the way when is the last time you managed an admitted patient?). The days of a patient with a DVT sitting inhouse for 5-7 days on a heparin gtt waiting to become therapeutic on coumadin are long over. But hey, don't believe me, I've just managed inpatients for over 20 years, I am sure you know better than I. You also gave NO DATA to support your statements about errors with work hours. Your opinion is fine, but opinions are like assholes, everybody has one. From the data I have read, the results area at best conflicting. Personally, I think work hours are not a bad idea as long as the residents are reading off the clock. I am saying that as someone who has taken real 36 hour call for the better part of two decades, not an ER doc who did it for has internship year off-service, and since then has worked 8-12 hour shifts. Your hypocrisy is hilarious.

The 'oldfarts' of the world (and I'm one of them) are missing the argument. The whole continuum of care nonsense that was inflicted on us way back when, was BS then, and is even more BS now.

The issue isn't 'do you want to re-explain your problem to doctors on every shift' because of rational work limits (we don't let airline pilots fly for 30 hours at a stretch, do we?), it's do you want a resident (by definition, a physician with less than full training) who has been working for 29+ hours (meaning without sleep for 30+ hours?) attempting to manage a NEWLY PRESENTING, critically ill patient? A patient who frankly wouldn't have been alive 25 or 30 years ago, at all?

Handoffs are a problem. The answer isn't in fewer handoffs, it's better systems to do them...protected time for the hand-over to occur, increased, staggered staffing, more supervision (which is more staffing), perhaps longer residencies (especially for skills-based specialties like surg - more staffing, again), better documentation (not more TJC or nursing manger bullshit), better documentation systems like a decent EMR, less boarding of patients in the ED, less CYA medicine, faster diagnostic studies, and all the other problems we suffer?

Frankly, while I may be an old fart (I'm 52, if thats an indication) I am appalled at the "I did it, so you have to, too" attitudes of some of my colleagues. Our mentors, way back when, used techniques and drugs that frankly killed people - why is one example of "doing it the old way" better, and another, with equal results, not?

BTW, I work at a rather large academic medical center/Trauma Center in a very major city, in the ED...

This is an interesting discussion to hear from both sides. I don't have much to add to the discussion. But I do have a question for the previous poster.

You state several times that more staffing is part of the solution. I dont' see hospital admins doing more staffing of anything. Hasn't their trend been to staff less and less trying to plug the holes with protocols, paperwork, and computer programs? How will they be convinced to employ more actual humans who cut into their bottom line?

"The problem with today(sorry I don't know how old you are) is nurses are getting taught to do paperwork and to actually believe they might be sued for malpractice for a poor pt outcome (that was the drs fault, not theirs)"

At my hospital I know of 4 nurses on my unit who have been named in lawsuits. Many of the OB's have been sued. Many have been settled out of court even when they did nothing wrong. We even started a group called Mal-anon to chat about what to do when we get sued.

Theoretically, if the nurse does not access the chain of command when a Doctor does something that is not appropriate. She can be liable. I have a girlfriend right now who is in that situation. It is unfair to expect nurses to police the Doctors behavior. But that is the climate I work in. I also work in L&D in a State that has more Lawyers than need be.

named in a suit is far from being liable. i have been named in many suits though i have never been found liable. in most suits i've been named i was named because my name was somewhere on the three hundred page chart. i would be very surprised if this were not the case with nurses. so, if there are any nurses out there who have had to pay any money in a malpractice suit, speak up. i think oldfart is right, nurse liability is nearly non existent apart from criminal behavior.

Dear Anon..My dick is bigger than yours!!Perhaps you practice somewhere where pts actually go upstairs..I don't. I routinely manage 10-15 admitted pts for 24 hrs plus while seeing another 30-40 pts at the same time. And we don't admit DVTs either. I routinely manage DKA until they don't need to go to the unit. Post stent MI's, and more.You, however, have managed admitted pts after I have stabilized them and managed them for you so you don't have to do shit, dickwad. You won't touch them until they are no longer critically ill. I do it, you pompous POS!And where did you train? Hobokkin? I guess so since your pts are "more" sick now. How fuckin funny. You came into the real world!! And I would love to lie in a bed a few hours while "on call" but no, I'm seeing new pts the entire time I'm working. You only get to see the ones I think are ill enuff to put in the hospital and after I've got them packaged for you.Yep, I only work 8 hrs at a time, but I and my compadres are THERE 24/7/365, seeing everyone who presents. Go back home and wait for a phone call Shithead!

Amy, you are right on..No answer for you..

Pinky what do you pay for malpractice insurance?? Me, 25K+/yr. I don't even keep track of it anymore..You are correct in that nurses should not have to police drs actions, that's why you have NO LIABILITY unless I order IV strychnine(sp) and you give it..

And our OB buddy's are the only ones to see shift duty as the way cover their responsibilities 24/7. My apologies and appreciation to all of them..

RR, you are right. I am too old for the reparte' I think I'll just shoot them all from now on..

Seriously, internet/forum/comment section skirmishes are fairly frustrating with very low payoff. I'm all over the "gun control"/gun enthusiast forums (don't want to start anything here), and it seems like that shit never ends. There's never an endgame; your enemies either disappear or just keep commenting with small permutations on a theme, ad nauseum. It's like the damn labor of Sisyphus, and frankly I don't see how you guys have the patience (especially 911). Guess you're right, pull the trigger before they can click "Publish Your Comment!"

Oldfart: Not sure how much I pay for insurance. I do know the OB fresh out of school pays 80 grand. YEs the OB's are the big pockets. But it is very stressful to be deposed and I am hoping to avoid that if possible. One of the ways we do this is by knowing the law better than most of the patients. At this point I am happier having a Lawyer as a patient than a lay person because then they know when they have a case.

I will check on the nurse being sued and found liable. I believe I have been to seminars that have indicated this. But I will check and get back to you.

I have not much original to add here except to reconfirm that training when I did, many years ago, produced, in the main, surgeons who had had a broad and deep experience while in training, and who, by virtue of sticking with the system then in place, declared themselves the type willing to place high quality and continuous care of patients above pretty much everything else. My friends in academic surgery have been saying for the past decade that the times are a-changin', and for the worse: surgical residents have a shift-worker mentality, are finishing training with less experience and commitment. I'm sure there are exceptions and if I were to need surgery, I'd hope my surgeon would be one. But I'd rather have me.

I see your point about handing off a patient to the next shift, but where does that end, exactly? If a patient comes in after the doc's been there 36 hours, does he have to stay another 36? I am asking honestly, because I don't know how you'd handle it, but at SOME point, you do have to hand off patients to the next person, right?

dear anonymous, good question. the way this is typically handled where i have worked is to get a disposition for the patient. in other words, get everything you can get done, done. do not leave procedures, like lumbar punctures or pelvic exams, for the follow-on doc. contact everyone that might be involved in the definitive care, and then wrap the patient up in a bow for your colleague. then they can simply make a call when the rest of the labs and CT scans etc... are done.

if you have to check out patients who are mid workup then i typically just tell the new doc to take the patient and get full credit for their workup.

short answer. people would die. reason, medical emergencies happen 24/7 and just because they are inconvenient is no reason to impose regs from above. the only reason VA hospitals run at all is because of residents and medical students who have no work hour restrictions. after hourse, at most VA hospitals you can not get a 'stat' anything unless you, the medical student or resident, do it yourself. this is true from drawing blood, to getting an EKG, to getting a special study or emergency surgery done.

also, as is true generally, a centralized entity can not possibly make rules that apply to chaotic situations.

what's the answer? i don't know because the residency and training programs are based on a hugely outdated model in which it was possible to know most of what was available to know in medicine by the time you got to your internship.

academic institutions survive on the backs of medical students (who pay for the privelege) and residents who make less tha minimum wage based on hours worked.

academic physicians are thereby liberated to do academic things and that's okay, but my solution would be to make medicine attractive as a career because if the pipeline of the ponzi scheme trickels down then regulations and rules will not matter at all, there won't be anyone there.

ha, you people think patient are being taken care of only in the US? Everywhere else in the Western world they have HUMANE way to train residents and nobodu suffers.The reason everybody is brainwashed about the necessity of this horror ( yes, 80 hour per week and 30 consecutive hours straight without sleep IS horror) in order to better train the physician is not better training, because you can't train half dead bodies to make life and death decisions, but pure old money - residents are cheap slaves - highly trained physicians duing the job for a wage which is the same as a babysitter's one - per hour.

Sorry, I have no medical background and am unable to give an opinion. Nevertheless, what strikes me, is the passage: "The reason for our previous long hours ... was continuity of care SO THAT a young physician would see a case... and see..." That is all very well, but, then, the first concern of care would be to teach.